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Nurse-Client Relationship and Effective Communication Techniques

Nursing 53AJudy Ontiveros, RN, MSN

Fall 2010

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Objectives• Explain the differences between a

nurse/client interaction versus a social interaction

• Describe the nature of the nurse/client relationship

• Define the progressive phases of a nurse/client interaction

• Discuss the different forms of communication and the importance of each

• Report the major factors affecting the nurse/client interaction

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Objectives• Discuss principles of effective

therapeutic communication.• Define and illustrate techniques

of therapeutic communication.• Interact effectively with patient,

staff and peers.• Discuss ways to report and

document important data accurately and in a timely manner.

• Discuss influences of cultural diversity in the communication process.

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Characteristics of the Nurse-Client Interaction

• Purpose• Therapeutic or Helping

Relationship• Growth facilitating process

• Initiation• Development of trust/acceptance• Belief that nurse cares and wants

to help

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Characteristics of the Nurse-Client Interaction

• Intellectual and emotional bond• Focused on client

• Respects the client as an individual• Includes patient in decision making• Considers ethical and cultural aspects• Considers family relationships and

values• Respects confidentiality• Focus on client’s well being• Based on mutual trust, respect,

acceptance.

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Characteristics of the Nurse-Client Interaction

• Empathy• “Intellectual process that involves

understanding correctly another person’s emotional state and point of view” Egan, 1998

• End result is comfort and care• Helping, healing relationship

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Nature of the Nurse-Client Relationship

• Caring and Human Dignity• People, relationships, and things

matter. • A positive difference is made for

clients• Caring practice

• Connection• Mutual recognition• Involvement

• Ability to give focused attention• Leave the egocentric self behind

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Nature of the Nurse-Client Relationship

• Caring – a multidimensional concept

• Theories developed around this concept• Leininger-Cultural Care• Ray – Bureaucratic Caring• Boykin and Schoenhofer-Nursing

as caring• Watson – Theory of Human Care• Swanson – Theory of Caring• Benner/Wrubel – Primacy of Caring

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Six C’s of Caring in Nursing• Compassion

• Participating in the experience of others• Competence

• Knowledge/skills to respond appropriately• Confidence

• Fosters trust• Conscience

• Personal responsibility• Commitment

• Desires, obligations, deliberation• Comportment

• ProfessionalismCaring, the Human Mode of Being. 2nd ed. M.S. Roach. 2002

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Maintaining Caring Practice

• Care for thine ownself• Healthy lifestyle• Mind body therapies

• Positive affirmations• Meditation• Yoga

• Reflection on practice • Journaling

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Phases of Nurse-Client Interaction

• Preinteraction Phase• Planning stage

• Introductory Phase• Orientation phase or prehelping

• Observation• Judgments

• Three stages• Opening the relationship• Clarifying the problem• Structure and formulate the plan

• Develop trust• Dispel Resistive behaviors

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Phases of Nurse-Client Interaction

• Working Phase• Share each other’s uniqueness• Deep sharing and concern about

the welfare of the client• Caring• Empathy grows

• Two stages• Exploring and understanding• Facilitating and taking action

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• Termination• Can be difficult and filled with

ambivalence• May have some feelings of loss• Summarizing/reviewing process

• Sense of accomplishment• Discussions on termination start

early in process• Follow-up phone calls

Phases of Nurse-Client Interaction

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Factors Influencing Nurse-Client Interactions

• Age and Development• Perception/knowledge level• Value/belief• Emotion• Sociocultural background/human

diversity• Role perception• Environment/space/territory

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Factors Influencing Nurse-Client Interactions

• Speech Patterns• Unknowing use demeaning or

patronizing language• Elderspeak

• “we”• “Honey”• Loud, slow speech

• Referring to cultural traits

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Forms of Communication

• Verbal

• Non-Verbal• Gestures• Facial Expressions• Touch

• Strive for congruency between the two

• Electronic Communications

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Principles of Therapeutic Communication

AltruismAutonomyObjectivity with sensitivityEmpathyVeracityAppropriate setting

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Therapeutic Communication

• Purposeful• Goal-directed• Focused on the patient• Includes verbal and non-

verbal communication• Open/authentic exchange of

information by developing rapport

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Therapeutic Communication

• Questions are general to specific• Less intrusive questions to

personal• Develop rapport and trust

• Give adequate time to respond• Never answer own questions

• Avoid judgmental questions• Use level of vocabulary matched

to patient

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Therapeutic Communication

• Attentive to appearance• General demeanor indicate interest• Always greet in a professional

manner• Avoid talking to others once begin

with patient

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Effective Communication Techniques

• Personalize the interview• Convey sincerity• Focus on patient• Link questions to something

patient has talked about• Make transition statements as

proceed through interview

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Effective Communication Techniques

• Use open ended questions• Prompt full answers• Provide more information• Examples:

• Tell me about your family• What are your concerns in caring for

your new baby?• Never ask “why”

• Close-ended questioned result in a yes or no answer• Use in biographic data• Use in emergency situations

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Effective Communication Techniques

• Make Broad Opening Statements• Patient plays an active role in the

interview• Establishes priorities for Discussion• Examples:

• Tell me about your accident• What brings you to the clinic today?

• Reflection• Repeating or paraphrasing a

person’s words or questions• Promotes further explanation and

descussion

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Effective Communication Techniques

• Verbalize implied ideas• Restating what patient has said• Adding some interpretation• Encourages further discussion• Gives patient opportunity to verify what they

said• Provide General Leads

• Inject leading phrases or responses• “Go on”, “And then what happened?”

• Seek Clarification• Clarify vague or confusing statements• I’m not sure I understand, could you

explain?

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Effective Communication Techniques

• Silence• Organize your thoughts• May be uncomfortable• Observe non-verbal cues

• Posture, facial expressions, body movements

• Open Body Language• Non-verbal cues• Maintain eye contact• Sitting relaxed

• Arms unfolded, lean toward patient• Facial expressions neutral

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Effective Communication Techniques

• Listen actively• Enhances assessment

• Concentrates attention on what patient is saying

• Enables you to consider subtle messages• Block out environmental distractions• Attentive behavior• Occasional verbal responses

• Share Perceptions• Share observation with person• “You appear to have some physical

discomfort today”• “It seems to me that ……”

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Effective Communication Techniques

• Confront Contradictions• Explore contradiction directly• “You tell me your not upset but you

look like your about to cry”• Review the Discussion

• Close with some type of summary• Discuss main points• Review in relation to goals of

interview

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Communication Patterns to Avoid

• Displaying Inappropriate Body Language• Continuous eye contact

• Too intrusive and intimidating• Know cultural norms

• Avoid showing alarm, anxiety, anger• Avoid standing over the person

• Portrays inequality and domination

• Proceeding Too Quickly• Avoid rushing through long list of

questions• No time to reflect on responses

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Communication Patterns to Avoid

• Offering Advice• Generally not helpful• May discourage decision making• “What would you do?” to “What would you

like to do?”• Abruptly Changing Subjects

• Disconcerting and disrupt rapport• Use transitional phrases when moving from

one subject to another• Acting Defensively

• Don’t defend people being criticized• Implies judgment and inhibit further

expression of feelings

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Communication Patterns to Avoid

• Minimizing Feelings• Disagreeing with person’s feelings =

denying person right to his/her own feelings

• “There is nothing to worry about”• Demonstrates lack of understanding or

empathy• Offering False Assurance

• Unfair and unrealistic• Denies reality of situation• Forces person to hide fears and anxiety

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Communication Patterns to Avoid

• Jumping to Conclusions• Always check out the facts

• Overweight• Wants to loose weight

• Breast Cancer patient• wants to have mastectomy

• Conclusions represent personal values and judgments

• May antagonize patient

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Cultural Considerations

• Profound effect on way people communicate• Sensitivity to culture influences interviews

• Cultural difference of great impact• Language• Verbal communication patterns • Nonverbal communication patterns

• Cultural variations• Beliefs about health and illness• Ways to express pain and emotions• Manner of decision making about health

and health care• May need to consult others of same

cultural on how to best communicate

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Cultural Considerations

• Observe Personal Space• Distance between individuals• Touch

• Appropriate Eye Contact• Rude, intrusive, immodest• Disrespectful for a woman to make

contact with man

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Cultural Communication Guidelines

• Translators• Rosters of translators• Family members or friends

• May not always be objective• Reluctant to divulge personal information

• Child, different gender, different age-group• Right to confidentiality and privacy

compromised

• Avoid Slang and Jargon

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Cultural Communication Guidelines

• Interpret Nonverbal Behavior• Clues for whether you are being

understood• Frown / blank stare

• Understand Variations in Expressions of Emotion and Pain• Crying may be childish or self-indulgent• Other vocal and physical in expressions

of pain

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Cultural Communication Guidelines

• Understand Variations in Disclosing Personal Information• Direct questioning viewed as intrusive,

rude, embarrassing• May be reluctant to participate in the

interview or give vague responses

• Determine Family Decision-Making Processes• How are decisions made and by whom• Who responds to questions when the

patient asked

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Report and Documentation • Change of Shift Reports

• Continuity of care• Oral report

• Given by charge nurse on all patients• Given between care givers• Tape Recorded

• Walking Rounds• Walk from bed to bed• Patient included in information shared

• Report focused on patient• No socialization

• Patient Record Forms

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SBAR Communication• Standardize communication among

health care workers• Promotes patient safety• Improves efficiency• Acronym

• Situation• Background• Assessment• Recommendations

• Uses• Calling physician• Handing off to another nurse• Transferring patients to another facility or

level of care